A nurse is caring for a client who is obese. The client is crying and states, "Everyone is staring at me because of my weight." Which of the following responses should the nurse make?

"How long have you struggled with your weight?"

"Let's discuss some weight loss strategies that might work for you."

"It sounds like you're saying that you feel uncomfortable around others."

"Have you always felt uncomfortable being overweight?"

Answer and Explanation

The Correct Answer is C

A. "How long have you struggled with your weight?" While this may provide background information, it shifts the focus to the client's weight history rather than validating their current emotional experience and distress.
B. "Let's discuss some weight loss strategies that might work for you." This response prematurely shifts to problem-solving and weight management without first addressing the client’s emotional needs or acknowledging their feelings of embarrassment and vulnerability.
C. "It sounds like you're saying that you feel uncomfortable around others." This is a therapeutic, reflective response that validates the client’s feelings and encourages them to express more about their emotional experience, fostering trust and emotional support.
D. "Have you always felt uncomfortable being overweight?" This question may come across as judgmental and focuses too much on the client's body image history rather than their current emotional experience, potentially worsening feelings of shame.

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Correct Answer is A

Explanation

A. The stoma appears dark purple in color. This is a priority finding, as it may indicate impaired circulation or necrosis of the stoma tissue. A healthy stoma should appear pink or red and moist. A dark purple or black color requires immediate evaluation.
B. The colostomy has had no output. While it is important to monitor output, it is not unusual for a new colostomy to have minimal or no output in the first 24–48 hours post-op as bowel function returns.
C. The client refuses to look at the colostomy. This is a psychosocial concern and may indicate body image issues or denial, but it is not the most urgent issue in the immediate postoperative period.
D. The client reports a pain level of 6 on a scale from 0 to 10. Pain management is important, but a pain level of 6, while needing intervention, does not take priority over a potential vascular compromise of the stoma.

A. Silence the bed alarm when visitors are at the client's bedside. B. Establish an elimination schedule for the client. C. Raise all four bed rails on the client's bed. D. Allow the client to walk unassisted near the nursing station

Correct Answer is B

Explanation

A. Silence the bed alarm when visitors are at the client's bedside. Bed alarms are a critical safety device for clients on fall precautions and should never be silenced when the client is in bed, regardless of visitors. Alarms alert staff if the client attempts to get up unsafely.
B. Establish an elimination schedule for the client. A regular toileting schedule helps reduce the risk of falls by preventing unassisted attempts to get out of bed to use the bathroom. This proactive approach supports both safety and comfort.
C. Raise all four bed rails on the client's bed. Raising all four rails is considered a form of restraint and can actually increase the risk of injury if the client attempts to climb over them. Two rails up is generally acceptable for support and safety.
D. Allow the client to walk unassisted near the nursing station. Clients on fall precautions should always be supervised or assisted during ambulation to prevent accidents, even when close to staff. Being near the nursing station does not eliminate the risk.

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A nurse is caring for a client who is obese. The client is crying and states, "Everyone is staring at me because of my weight." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who had a colostomy 24 hrs ago. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

A nurse is caring for a client who is on fall precautions. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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